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Phys Ed: Does Ibuprofen Help or Hurt During Exercise?

Several years ago, David Nieman set out to study racers at the Western States Endurance Run, a 100-mile test of human stamina held annually in the Sierra Nevada Mountains of California. The race directors had asked Nieman, a well-regarded physiologist and director of the Human Performance Laboratory at the North Carolina Research Campus, to look at the stresses that the race places on the bodies of participants. Nieman and the race authorities had anticipated that the rigorous distance and altitude would affect runners’ immune systems and muscles, and they did. But one of Nieman’s other findings surprised everyone.

After looking at racers’ blood work, he determined that some of the ultramarathoners were supplying their own physiological stress, in tablet form. Those runners who’d popped over-the-counter ibuprofen pills before and during the race displayed significantly more inflammation and other markers of high immune system response afterward than the runners who hadn’t taken anti-inflammatories. The ibuprofen users also showed signs of mild kidney impairment and, both before and after the race, of low-level endotoxemia, a condition in which bacteria leak from the colon into the bloodstream.

These findings were “disturbing,” Nieman says, especially since “this wasn’t a minority of the racers.” Seven out of ten of the runners were using ibuprofen before and, in most cases, at regular intervals throughout the race, he says. “There was widespread use and very little understanding of the consequences.”

Athletes at all levels and in a wide variety of sports swear by their painkillers. A study published earlier this month on the website of the British Journal of Sports Medicine found that, at the 2008 Ironman Triathlon in Brazil, almost 60 percent of the racers reported using non-steroidal anti-inflammatory painkillers (or NSAIDs, which include ibuprofen) at some point in the three months before the event, with almost half downing pills during the race itself. In another study, about 13 percent of participants in a 2002 marathon in New Zealand had popped NSAIDs before the race. A study of professional Italian soccer players found that 86 percent used anti-inflammatories during the 2002-2003 season.

A wider-ranging look at all of the legal substances prescribed to players during the 2002 and 2006 Men’s World Cup tournaments worldwide found that more than half of these elite players were taking NSAIDS at least once during the tournament, with more than 10 percent using them before every match.

“For a lot of athletes, taking painkillers has become a ritual,” says Stuart Warden, an assistant professor and director of physical therapy research at Indiana University, who has extensively studied the physiological impacts of the drugs. “They put on their uniform” or pull on their running shoes and pop a few Advil. “It’s like candy” or Vitamin I, as some athletes refer to ibuprofen.

Why are so many active people swallowing so many painkillers?

One of the most common reasons cited by the triathletes in Brazil was “pain prevention.” Similarly, when the Western States runners were polled, most told the researchers that “they thought ibuprofen would get them through the pain and discomfort of the race,” Nieman says, “and would prevent soreness afterward.” But the latest research into the physiological effects of ibuprofen and other NSAIDs suggests that the drugs in fact, have the opposite effect. In a number of studies conducted both in the field and in human performance laboratories in recent years, NSAIDs did not lessen people’s perception of pain during activity or decrease muscle soreness later. “We had researchers at water stops” during the Western States event, Nieman says, asking the racers how the hours of exertion felt to them. “There was no difference between the runners using ibuprofen and those who weren’t. So the painkillers were not useful for reducing pain” during the long race, he says, and afterward, the runners using ibuprofen reported having legs that were just as sore as those who hadn’t used the drugs.

Moreover, Warden and other researchers have found that, in laboratory experiments on animal tissues, NSAIDs actually slowed the healing of injured muscles, tendons, ligament, and bones. “NSAIDs work by inhibiting the production of prostaglandins,”substances that are involved in pain and also in the creation of collagen, Warden says. Collagen is the building block of most tissues. So fewer prostaglandins mean less collagen, “which inhibits the healing of tissue and bone injuries,” Warden says, including the micro-tears and other trauma to muscles and tissues that can occur after any strenuous workout or race.

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The painkillers also blunt the body’s response to exercise at a deeper level. Normally, the stresses of exercise activate a particular molecular pathway that increases collagen, and leads, eventually, to creating denser bones and stronger tissues. If “you’re taking ibuprofen before every workout, you lessen this training response,” Warden says. Your bones don’t thicken and your tissues don’t strengthen as they should. They may be less able to withstand the next workout. In essence, the pills athletes take to reduce the chances that they’ll feel sore may increase the odds that they’ll wind up injured — and sore.

All of which has researchers concerned. Warden wrote in an editorial this year on the website of the British Journal of Sports Medicine that “there is no indication or rationale for the current prophylactic use of NSAIDs by athletes, and such ritual use represents misuse.”

When, then, are ibuprofen and other anti-inflammatory painkillers justified? “When you have inflammation and pain from an acute injury,” Warden says. “In that situation, NSAIDs are very effective.” But to take them “before every workout or match is a mistake.”

While surprising, this makes sense to me.
Several years ago, while approaching my 40th year and about to run the NYC marathon for the 3rd time, I asked my swim coach if he had any tips for the older athlete.
He said “Sure, there is a secret – Ibuprofen. Take 800 mg the night before the race, 800 mg with breakfast before the race, and 800 mg after the race.’
I followed his advice to the letter, experienced no pain whatsoever during the race, no soreness afterward, and ran my fastest race ever.
I was amazed at the Ibuprofen effect.
But 1 month later, seemingly out of the blue, I suffered a knee injury after a month of rest and minimal exercise.
Could the Ibuprofen been the cause?
My other non-Vitamin I endurance events were associated with great suffering and extreme soreness afterwards but no injuries.
Today i no longer use Ibuprofen prophylactically, only when for headache or injury.

“Those runners who’d popped over-the-counter ibuprofen pills before and during the race displayed significantly more inflammation and other markers of high immune system response afterward than the runners who hadn’t taken anti-inflammatories.”

Doesn’t it make sense that runners with major joint inflammation issues *in the first place* were also the ones who tended to take more ibuprofen than the runners who didn’t have major inflammation issues?

“In a number of studies conducted both in the field and in human performance laboratories in recent years, NSAIDs did not lessen people’s perception of pain during activity or decrease muscle soreness later. “We had researchers at water stops” during the Western States event, Nieman says, asking the racers how the hours of exertion felt to them. “There was no difference between the runners using ibuprofen and those who weren’t. So the painkillers were not useful for reducing pain” during the long race, he says, and afterward, the runners using ibuprofen reported having legs that were just as sore as those who hadn’t used the drugs.”

Once again, the question is: do the runners who take large amounts of ibuprofen feel *less pain* than they would have felt if they had not taken the large amounts of ibuprofen? Obviously, the runners who experience less inflammation and soreness due to genetics and/or personal conditioning are going to feel less of a need in general for taking anti-inflammatory meds, and are pretty likely to feel better in general than those athetes with chronic injuries and chronic inflammation.

I love that stuff, especially as I’ve gotten older (>40), but the fact is I have to avoid excercise that makes my joints sore. Makes sense, but it’s not very “Just Do It”.
I like my kidneys, and collagen too. Didn’t Alonzo Mourning take a lot of Vitamin I? That was the first time I remember hearing something about ibuprofen.

I always thought there was an ergogenic effect in how NSAIDS dilute the blood and increased plasma volume and that was somehow beneficial for aerobic exercise. Though I think blood doping works the other way, by thickening the blood with more hemoglobin. Also I’ve heard aspirin enhances the affects of caffeine, another favorite drug of runners and athletes alike! tell me caffeine doesn’t enhance performance!

When I started endurance events, including 3 day canoe events, 100 mile runs, and others, the common thought was preemptive NSAIDS. before the start, and during the race. I will see now about changing my habits. However, I will still replace electrolytes. with preemptive regularity – before, during and after.

A fascinating study. I have used Ibuprofen myself in this way for a knee injury, although luckily I have not had to do so recently.

I agree with Sorenzo (Comment #3); With the description given, it is obviously difficult to have a controlled experiment. Those athletes who had a history of joint pain or whatever, are more likely to take painkillers prophylactically. There would need to be some determination at the start of the race of the background of each of the racers, and then correct the results accordingly to provide more of a direct comparison of athletes with similar injury/pain background, some who took NSAID and others who did not.

If the pain levels taken by poll at the rest stops were even between athletes, then that could just as easily lead one to conclude that the NSAIDs *were effective* in preventing pain that would otherwise be excessive.

A couple of other opinions that I see in myself and other athletes that may contribute to this;
It is a common perception (misconception?) that some types of pain or inflammation are easier to prevent than to cure aferwards. Hence the use of tablets beforehand.

Perhaps part of the problem is that you don’t always have the option to rest your injury if you have a schedule or event that you are committed to keeping.

My experience is with Diclofenac Sodium, aka Voveron. Available in some jurisdictions without prescription in low-doses. I never need to take it before a workout, but it does help one sleep better and works wonder with with delayed onset soreness.

This really does help getting to work the next morning, and I think I’d be willing to trade off some delayed healing and inflammation for the increased productivity at work.

To make it possible to endure the pain of bone-on-bone “activated post-traumatic arthrose” of the ankle, I’m now taking (rx) Diclofenac retard, 200 mg., and for “break-through pain” on really bad days, Ibuprofen in addition. With the pain meds, I can walk fairly well, but not too long. Bad days usually have to do with big weather changes or trying to carry too much. BUT, do all of these meds just mean that any little bits of cartilage that might have regrown will not be able to do so? Even at the cost of more limping and less mobility, should I just try to grin and bear the pain? I’m exploring the possibility of an ankle replacement, primarily so that I won’t have to live on pain meds, but has my pain threshold been so lowered by constant medication that I will still need meds for the post-op phase? Would my post-trauma arthritis never have gotten worse if I had NOT taken pain meds after the 3 ops I had for my shattered ankle? The more I learn, the less I seem to know……

There’s even controversy about using NSAIDS after suffering painful soft tissue injuries. Though they do reduce pain in such circumstances, as mentioned in this article, they may impair or prolong healing in the long run.

Whould the same hold true for asprin? I’m 54 years old and usually take two asprin tablets about 1/2 hour before playing basketball. I know of many that take tylenol or advil but none that take asprin like me.

As a seasoned neurologist and neurophysiologist,I prescribe daily ibuprofen,an excellent drug for its clinical purposes.However,particularly in Fibromyalgia,a frequent source of muscular pains,it works quite well,but other medications must be associated,in order to treat the subjacent causative factor,frequently anxiety and frustration,and an extensive list of other complaints and physical/psychological conditions.We never use big dosages of an excellent drug,cheap and reliable and alone,for it woul veil other causes of muscular pains.
I think it is almost criminal for technicians,to envolve athletes in automedication,particularly in high strained conditions,like competitions.
Other painkillers for muscular strain abound,but its use, must comply with medical principles,never with such unwise use.Athletes must be more respected than medals,for they will become old,and are endowed with only one organism,for life.
lincoln

I’ve done various ultra-endurance events before: cycling solo 3000 miles in under 3 weeks, cycling 12 hours straight (221 miles), swimming 6 hours without so much as a drink break, and dancing for 24 hours without even stopping to eat. I push myself to see how far and fast my body can go; to see how much my will can propel me and my focus can sustain me; to see what I can accomplish. I do not care to see how far supplements or drugs can take me. I want the full human experience of mobility, and pain and soreness are important parts of that, giving valuable feedback, empowering me with necessary and relevant information. Shortcuts are for those focused on the destination, who forget that life is what happens to us on the journey. Instead of popping painkillers like candy, eat better (fresh, whole food) and train smarter (including rest and recovery).

I take aspirin for tendinitis before prescribed physical therapy exercises, icing, and weight training which involves the effected tendons. I have been able to maintain a rigorous and successful training schedule, at 63, without ill effect, either from the aspirin or the training. My physical therapists advised aspirin and my doctor approved its use as the safest and most effective of the anti-inflammatories, prescription drugs included. I have found it so.

I agree that athletes shouldn’t be taking Ibuprofen as it were a vitamin or candy. However I get suspicious when a scientist at a university sets out to prove that a drug doesn’t do what it is purported to do. Often when you scratch the surface you find that their research is funded by a competitor, say Johnson and Johnson (or one of its down the line foundations or affiliates), maker of Tylenol? Why else would you get funding for research in an area where there doesn’t really seem to be a problem?

This makes a lot of sense. Inflammation following exercise is a protective response. It is also a regulated response. If you thwart the regulation of that response by inhibiting it, the control system is likely to turn up the gain to overwhelm the inhibition.

All of those inflammatory signals are the same signals that your physiology uses to adjust the setpoint of muscle strength, bone stiffness, ligament strength. If the inflammatory signal is suppressed, the body doesn’t “know” that the tissue compartment was “stressed” and needs to be made more robust, so it doesn’t.

Sorry to “repost” this. Mentioned it last week in the discussion about arthritis pain:

Joe Graedon, of the People’s Pharmacy says, “Most athletes rely too much on “Vitamin I” or ibuprofen for aches, pains & injuries, which can raise blood pressure and are hard on the stomach.” (kills my stomach!)

He adds (and pay attention to this one!) that Joe Maroon, the team neurosurgeon for the Pittsburgh Steelers advocates against ibuprofen for aches & pains, and advises his team members to get an adequate intake of fish oil.

Not only does it reduce pain and inflammation, but it lowers triglycerides, which are often elevated in football players who eat diets high in refined sugar and carbs.

My brother-in-law seriously damaged his kidney function from ibuprofen use for a disc problem–and is advised to never take it again.

There are too many negative side effects to this over-the-counter drug to advise its use for anything other than an acute injury.